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STATE OF CALIFORN WATER RESOURCES CONTR BOARD FORM 'B': UND GROUND STORAGE TANK PR RAM (oz TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT HANGE OF INFORMATION N ONE ITEM ❑2 INTERIM PERMIT ❑ 7 PERMANENTLY CLOSED TANK ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ARM TANK-YES❑ NO ❑ 4111, I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# S. MANUFACTURED BY: CA) C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / HAZARDOUS SUBSTANCE STORED&C.A.S.# /`l// C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑1 DOUB�ALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ILS,-�•,'INNG ALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER B.TANK 1 STEBUIRON E]2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEELCLAO W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%MEfBANOLOOMPATIBLEFRP ❑9 BRON2 ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR LIBBER LINED 2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLIC LINING ❑ LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYEIHLENEWRAP ❑2 T ASPHALT ❑3 VINYL WRAP ❑q FIBERGLASS REINFORCED PLASTICPROTECTION ❑5 CATHODIC PROTECTION 1 NONE F-195 UNKNOWN r--'99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY B.CONSTRUCTION A U I SINGLE WALLED A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 459AGLASS PIPE A U 9/ NONE C.MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U 9 GALVANIZED STEEL U 5 UNKNOWN A U B 100%METHANOL COMPATIBLE FRP A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING 0 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHEfl VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED MO/YR) 2. ESTIMATED C I IN OF / / SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH GALLONS INERT MATERIAL? (DYES ❑ NO THIS FORM HAS B EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) GATE LOCAL AGENCY USE ONLY C'O�)UTNTTYY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# J APPROVED BY NA E op PERMIT PHONE#WITH AREA CODE PERMIT NUMB R PERMIT APPROVAL DATE PERM EXPIXA DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTp BY FORM B S-29-s8) THIS FORM MUST BE ACCOMPANIE o A FACILITY/SITE APPLICAT FORM 'A',UNLESS A ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY �)